Differential diagnosis with intervention of spine, pelvis, and TMJ Spine and pelvis differential diagnosis
Spinal or intervertebral stenosis
Narrowing of spinal canal or intervertebral foremen
Can cause neurological or vascular dysfunction
Symptoms
Bilateral back, buttocks, and leg pain
Pain increases with extension
Pain increases with walking
Pain decreases with flexion and/or rest
Diagnosis
Clinical presentation
Special tests- bicycle test
MRI
CT imaging
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Flexion based exercises that centralize pain
Dynamic stability for trunk and pelvis
Manual therapy
Avoidance of extension, ipsilateral side-bending, and ipsilateral rotation
Facet joint dysfunction (two types: degenerative joint disease, facet entrapment)
Degenerative joint disease
Causes bone hypertrophy, capsular fibrosis, hypermobility or hypomobility at joint caused by natural process of aging
Occurs due to repetitive weight bearing of facets and intervertebral joints over life-span
Symptoms
Localized pain in the neck, back, or buttocks
Pain that worsens with certain movements, such as bending, twisting, or standing for long periods of times
Pain that radiates into the arms, legs, or shoulders
Difficulty moving the neck or back
Morning stiffness that improves with activity
Diagnosis
Clinical presentation
Special test- quadrant test
X-ray
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Spinal mobilization as appropriate
Exercise promoting dynamic stability of trunk and pelvis
Facet entrapment (acute locked back)
A condition where the small joints (facet joints) connecting vertebrae in the spine become inflamed or damaged, causing pain and potentially restricting movement
Symptoms
Dull, aching pain in the back or neck, which can worsen with certain movements or activities
Difficulty moving the spine - flexion is most comfortable for patient
Spasms in the back or neck muscles as a protective response to the pain.
Can cause nerve irritation can cause numbness or tingling in the arms, legs, or buttocks.
Diagnosis
Clinical presentation
Special test- quadrant test
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Facet manipulation to improve mobility
Disc Conditions
Internal disc disruption
Internal annulus is disrupted while outside structures remain intact
Symptoms
Chronic, central low back pain
Pain worsens with activity and loading the spine
Muscle spasms.
Pain may be constant or episodic
No neurological findings
Diagnosis
Clinical presentation
CT scan
MRI
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Joint mobilization
Patient education on biomechanics and positions to avoid
Posterolateral bulge/herniation
Overstretching or tearing of annular rings, vertebral endplate, and or ligamentous structures due to high compressive forces or repetitive trauma
Symptoms
Radicular pain
Lower extremity weakness
Lower extremity paresis
Diagnosis
Clinical presentation
MRI
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Improve dynamic stability of trunk and pelvis
Spinal manipulation
Manual traction
Positional gapping
Patient education on biomechanics
Central posterior bulge herniation
Overstretching or tearing of annular rings, vertebral endplate, and or ligamentous structures due to high compressive forces or long term postural misalignment
Move common in cervical spine
Symptoms
Radicular pain
Lower extremity weakness
Lower extremity paresthesia
Possible compression of spinal cord causing upper motor neuron lesion
Diagnosis
Clinical presentation
MRI
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Improve dynamic stability of trunk and pelvis
Spinal manipulation
Manual traction
Positional gapping
Spondylosis
Spondylosis is a degenerative condition of the spine that involves changes in the intervertebral discs and facet joints, commonly referred to as spinal osteoarthritis.
Can be caused by degeneration of the intervertebral disc (disc desiccation), formation of osteophytes (bone spurs), or possible narrowing of the intervertebral
Symptoms
Gradual onset of chronic back pain and stiffness, especially in the cervical and lumbar spine
Limited range of motion, especially extension and rotation
May be asymptomatic or cause radicular symptoms if nerve compression occurs
Diagnosis
X-ray: Reduced disc space, osteophyte formation, facet joint changes
MRI: Assesses neural compression and disc degeneration
Medical management
NSAIDs pain and inflammation
Muscle relaxants if muscle spasms are present
Corticosteroid injections (epidural or facet joint) for nerve root involvement
Surgical intervention (e.g., decompression or fusion) in cases of severe stenosis or myelopathy
Physical therapy management
Postural education and ergonomic training
Stretching of tight musculature (e.g., hamstrings, hip flexors)
Strengthening of spinal stabilizers, especially deep core muscles
Manual therapy to improve mobility
Aerobic conditioning (walking, cycling)
Education on activity pacing and joint protection
Spondylolysis
Stress fracture or defect in the pars interarticularis, the segment of bone between the superior and inferior articular processes of a vertebra.
Often occurs due to repetitive hyperextension, particularly in young athletes
Most commonly affects the L5 vertebra
Symptoms
Localized low back pain, worsened with lumbar extension
Possible tight hamstrings
Usually no neurological symptoms
Diagnosis
Oblique lumbar X-ray: Shows “Scotty dog with a collar” appearance
CT or MRI may confirm the presence of the defect
Medical management
Activity modification (rest from extension-heavy sports)
NSAIDs for pain relief
Bracing (e.g., lumbosacral orthosis) to allow healing
In rare non-healing cases, surgical fixation
Physical therapy management
Education: Avoid extension-based movements initially
Core stabilization exercises (neutral spine control)
Hamstring stretching and hip mobility work
Gradual return to sport with movement re-education
Emphasis on lumbar-pelvic control during dynamic a
Spondylolisthesis
Anterior slippage of one vertebra over the vertebra below it. It may be the result of spondylolysis (isthmic) or degenerative changes.
Types
Isthmic: Due to bilateral pars defects (common in younger individuals)
Degenerative: Due to facet joint and disc degeneration (common in older adults)
Symptoms
Low back pain with or without radicular symptoms
Tight hamstrings and altered posture
Palpable step-off deformity
In severe cases, may present with neurological deficits
Diagnosis
Lateral X-ray: Shows degree of vertebral slippage (graded I–V based on percent displacement)
MRI: Identifies soft tissue or neural involvement
Medical management
NSAIDs, acetaminophen, or muscle relaxants for pain
Epidural steroid injections if radiculopathy is present
Bracing for pain control and stability
Surgical intervention (e.g., spinal fusion) in cases of high-grade slippage or neurological compromise
Physical therapy management
Core strengthening to stabilize the lumbar spine
Postural retraining
Avoid lumbar hyperextension and heavy axial loading
Stretching tight muscles (especially hamstrings)
Manual therapy for adjacent segment mobility
Progressive return to activity under supervision
Education on body mechanics and functional movement patterns
Whiplash associated disorders (WAD)
Occurs in cervical spine when excess shear and tension occur on the structures of the cervical spine
Structures damaged are facets/articular processes, facet joint capsule, ligaments disc, anterior/posterior muscles, fracture to odonotoid process, TMJ, spinal nerves, cranial nerves
Symptoms
Heachaches
Limited mobility
Vertigo
Hearing loss or ringing in the ears
Difficulty swallowing
TMJ dysfunction
Disequilibrium
Anxiety
Diagnosis
Clinical presentation
MRI
CT scan
X-ray
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Spinal manipulation
Patient education on biomechanics and positions to avoid
Joint mobilization
Functional training
Sacroiliac joint conditions
Causes of dysfunction can be inflammation, degenerative changes, or abnormal movement patterns
Can be associated with lumbar spine so will need to examine both when pain reported
Symptoms
Lower back pain, often on one side
Pain that radiates to the buttocks, hips, or thighs
Pain that worsens with activities such as sitting, standing, or walking
Stiffness in the lower back or hips, especially after sitting for long periods
Diagnosis
Clinical presentation
Special test- SI gapping, SI compression, Gaenslens test
MRI
X-ray
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Spinal manipulation
Patient education on biomechanics and positions to avoid
Joint mobilization
Functional training
Sacral Spondylolisthesis
Forward slippage of the sacrum or L5 over the sacrum due to instability such as trauma, stress fractures, or degenerative changes
Symptoms:
Low back pain (worse with extension).
Sacral/hip pain.
Tight hamstrings.
Possible nerve compression leading to leg pain or weakness.
Diagnosis:
Clinical presentation
X-ray
MRI
CT scan
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Treatment
Core stabilization exercises.
Physical therapy for posture correction.
Bracing for mild cases
Upslip of the Ilium (Superior Ilium Displacement)
The ilium on one side moves superiorly relative to the sacrum.
Common causes:
Trauma (e.g., stepping off a curb forcefully, falling on one side), muscle imbalances .
Impaired (Weak/Lengthened) Muscles:
Gluteus medius & gluteus minimus (difficulty stabilizing the pelvis).Quadratus lumborum (opposite side) (overstretched and weak).Hip adductors (on the affected side, often lengthened).
Tight/Overactive Muscles:
Quadratus lumborum (same side) (shortened, pulling the ilium superiorly).Iliopsoas (on the affected side, can contribute to pelvic asymmetry).Hamstrings (may compensate for instability).
Downslip of the Ilium (Inferior Ilium Displacement)
The ilium on one side moves inferiorly relative to the sacrum.
Common causes:
High-impact trauma, instability in the sacroiliac (SI) joint.
Impaired (Weak/Lengthened) Muscles:
Quadratus lumborum (same side) (overstretched and weak).**Gluteus medius & gluteus minimus **(lack of pelvic stability).
Hip abductors (due to altered pelvis positioning).
Tight/Overactive Muscles:
Hip adductors (same side) (contracting to stabilize the pelvis).Quadratus lumborum (opposite side) (may tighten in compensation).
TMJ conditions
Can be due to
Osteoarthritis, rheumatoid arthritis
Myofascial pain- pain in muscles controlling TMJ
Dislocation of jaw
Symptoms
Joint noise when opening mouth
Joint locking
Loss of range of motion
Lateral deviation during depression or elevation of mandibile
Decreased strength of mandible
Headache
Ringing in ears
Forward head posture
Can have cervical spine pain
Diagnosis
Clinical presentation
X-ray
MRI
Medical management
Acetaminophen or non-steroidal inflammatory (NSAIDs)
Corticosteroids
Muscle relaxants
Physical therapy management
Patient education on biomechanics and positions to avoid
Joint mobilization
Biofeedback
Modalities for pain and inflammation
Night splinting
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